Exam One portion of exam Flashcards
________________ are the gold standard of medications, must be proven to have the same therapeutic effect on the body no matter who makes it.
preferred agents
_________ is the study of what the body does to the drug when administered
pharmacokinetics
pharmacokinetics
is the study of what the body does to the drug when administered
the extent of absorption
bioavailability
bioavailability
the extent of absorption
typically less than 100% bioavailability
oral medications
oral medications typically have ________ bioavailability
less than 100%
IV medications typically have _____ bioavailability
100%
typically have 100% bioavailability
IV medications
______ – the extent of absorption ( is higher with an IV for example, is typically 100%)
bioavailability
______ – time for drug to actually illicit therapeutic response from administration
time to onset
______ – time for drug to reach its maximum therapeutic response
time to peak effect
_____ –the maximum concentration of the drug in the body after administration
peak level
______ – length of time the concentration of the drug in the blood or tissues is sufficient to actually illicit a response
duration of action
Movement of a drug from its site of administration into the bloodstream for distribution to the tissues
absorption
Refers to the transport of a drug by the bloodstream to its intended site of action
distribution
if there is good blood supply there will be ______distribution
rapid
Most often occurs in the liver, but can happen in the skeletal muscle, kidneys, lungs, plasma and intestinal mucosa.
metabolism
______ – phenomenon where drug is metabolized in a certain part of the body and it is reduced by the time that it gets to the intended target site
first pass effect
________ is the fraction or %U of a drug that reaches systemic circulation, IV are 100 % ______
bioavailability
primary organ of excretion?
kidney
(the bowels also excrete, but not as much)
Time required for one-half of a given drug to be removed from the body
half life
the interactions between the medicine and target cells, body systems, and organs to produce effects
pharmacodynamics
–through drug receptor interaction, so what happens is a drug molecule joins a reactive site on a cell to produce a response
receptor interactions
– enzymes are substances that break down almost every biochemical reaction in a cell, drugs can produce effects by interreacting with these enzyme systems by either inhibiting or enhancing the enzyme.
enzyme interactions
– actually interact with the cell membranes or cellular processes, drugs either physically or structurally interfere cellular processes. example is a cancer drug (pretty harsh)
nonselective interactions
two solutions mixed together than are ______, when they are mixed they create a precipitate which can cause an embolism, as well as the drugs not working properly
incompatible
–goes over the hospital to hold the standard of care where it needs to be.
the Joint commission (Medicare does this too)
– develop standards for nurses, do policy statements and resolutions
ANA
– promoting patients informed decision making, supporting their informed decision
autonomy
– doing or actively promoting good, whatever you do is to best help the patient
beneficence
– respecting privileged information, known when to include or not include family
confidentiality
– being fair and ethical in your actions
justice
– avoiding doing deliberate harm
nonmaleficence
– duty to tell the truth, informed consent
veracity
- Complete all forms including incident report according to facility policy and procedure
- Factual information only
- Avoid judgmental words
- Document changes in patient’s physical or mental status
- Document that physician was notified (who, time, follow-up actions/orders)
- Ongoing patient monitoring
reporting/documenting med error
Younger than 38 weeks of gestation is a ?
premature
Younger than 1 month?
neonate
1 month up to 1 year
infant
1 year up to 12 years
child
Immature Organs
Especially Liver and Kidneys excretion impaired
Limited medication-metabolizing capacity
Sensitivity of receptor sites vary with age
Skin is thinner
neonatal and pediatric patients characteristics that affect dosage
Rapidly developing tissues may be more sensitive to drugs
Stomach acid (pH) is less acidic decreased ability to kill bacteria
Lungs have weaker mucous barriers
Body temp is less well regulated and dehydration occurs easily
less stomach acid
peristalsis is slower
neonatal and pediatric patients characteristics that affect dosage
What trimester is the highest risk for adverse effects to happen to the fetus?
1st trimester
Functioning of Organ Systems Declines
Drug Sensitivity is Altered
General Decrease in Body Weight
Malnutrition
Changes in Drug Molecule Receptors
Important to Monitor Liver and Kidney Function Via Labs
age considerations for elderly
1 gram
1000 mg
1 mg
1000 mcg
1 L
1000 mL
3 teaspoons (tsp)
1 Tablespoon (T)
1 cc
1 mL
1 teaspoon (tsp)
5 mL
1 table spoon (T) = ____ mL
15 mL
1 kg
2.2 lbs
1 oz
30 mL
1 in
2.54 cm
tachycardia
tinnitus
hearing loss
dimness of vision
headache
dizziness
n/v
diarrhea
sweating thirst
hyperventilation hypoglycemia
s/s chronic salicylate toxicity
most common in adults: tinnitus (first sign) and hearing loss
most common in children: drossiness, hyperventilation, hypoglycemia
Strong abuse potential
Sedation, dizziness, lightheadedness, drowsiness
Itching or pruritus, rash and hemodynamic changes
Respiratory depression – most severe adverse effect
GI tract adverse effects
Urinary retention
Severe hypersensitivity or anaphylactic reaction
Cough suppression
orthostatic hypotension
itching (histamine release)
adverse effects of opioids
Monitor vitals and auscultate lungs for congestion
For respiratory rates < 12, withhold drug and stimulate breathing
Administer an _____ antagonist (Narcan) to restore respiratory rate
Fall precautions (orthostatic hypotension)
Monitor bowel function, encourage fiber supplements, stool softeners
For vomiting, administration of antiemetic, ensure adequate hydration
Monitor I&O, watch for urinary retention, bladder distention
Encourage patients to urinate every 4 hours (perception of need decreases)
Prepare to insert catheter as needed to empty bladder
Encourage to cough frequently to prevent buildup of respiratory secretions (especially postop)
Recommend lowest possible dose and short term only
interventions for opioids
Measure baseline vitals and monitor throughout therapy
Administer orally, IM, IV, SC, rectally, epidurally
Swallow without crushing or chewing if sustained release
Administer IV opioids by diluting as recommended and slowly; have naloxone and resuscitation equipment available
Monitor PCA and pump setting carefully
Administer to cancer patients on a fixed around the clock schedule rather then PRN
opioids administration
don’t drive heavy machinery when first starting _____
sit down if you get light headed
drink lots of water,
move around (prevents constipation and pneumonia)
rise slowly from a reclining or sitting position
report any problems with urination
cough and breath deep regularly (pneumonia prevention)
nausea vomiting problems – take with food first, if it persists use an antiemetic
take the opioids as prescribed
opioids patient instructions
Known allergy
Severe Asthma
Pregnancy Risk Category D
Renal failure
Increased intracranial pressure
Biliary colic or biliary tract surgery
Preterm labor
contraindications for opioids
Can be used transdermally (for long term)
Strong opioid analgesic
Rapid onset/Short duration when injected
Caution! Disposal of Patches
Binds with opioid receptors in brain and spinal cord to inhibit pain transmission (acts like a closed gate to block pain transmission)
fentanyl
For Severe Pain
Schedule II
Mainly used - oral and parenteral routes
“Non-ceiling” drug
morphine
More effective than most opioids given orally
Larger doses for analgesia than antitussive
Metabolized to morphine
not as strong as morihine, but has fewer side effects
codeine
Similar to codeine in analgesic and antitussive effects
Schedule II
Metabolized to hydromorphone
metabolizes to hydromorophine, is given with Tylenol or ibuprophen
hydrocodone
Schedule II
Synthetic
Action similar to morphine, more frequent administration
Normeperidine
Use has greatly declined
Drug Interactions
can cause less smooth muscle spasm, so less biliary and renal cholic with this drug
meperidine
normeperidine –is toxic and can accumulate with chronic use or large doses, or with someone in renal failure who is taking ______
this is nonreversable, there is not a reversal drug that you can give
contraindicated in anyone who is taking amphetamines or MAOI in the last three weeks because it can lead to serotonin syndrome
serotonin syndrome leads to high fever, seizures, and death
meperidine
Can occur after only 2 weeks of opioid use
Gradual dosage reduction minimizes risk
S&S if someone is in withdrawal: they may be drug seeking, their eyes can be dilated (madriasis), piloerection (hair is standing up on body), very diaphoretic (really sweaty, cold, clammy), rhinorrhea (runny nose), lacrimation (overproduction of tears), vomiting and diarrhea, CO insomnia, elevated bp and pulse, CO muscle cramps, CO arthralgia (pain in joint), super anxious, physically painful to some people
opioid withdrawl
Schedule IV controlled substance
History of substance abuse
Head injury, increased intracranial pressure
Decreased respiratory reserve
Hepatic or renal disease
Agonist-Antagonists - Precautions
Reversal of opioid effects, overdose
Reversal of neonatal respiratory depression due to maternal analgesia
Most reverse respiratory depression, some will reverse constipation and euphoria; overdose
Opioid Antagonist - Indications
Blocks opioid receptors
Binds to a pain receptor but does not reduce pain signals.
Competes with and reverses the effects of agonist and agonist-antagonist drugs at the receptor sites
Opioid Antagonist – Pharmacologic Action
IV, IM, subQ, Intranasal
Remember the half-life of ______ is much shorter than that of opioids so may have to give more________; monitor!!!
Will produce withdrawal symptoms when given to opioid dependent people
can cause seizures, other withdrawal symptoms when given to opioid dependent people
expect upset person when narcaned if they just came out of surgery
KNOW THE DOSAGES FOR EMERGENT DRUGS, NARCAN IS AN EMERGENT DRUG
Opioid Antagonist Prototype = Narcan (naloxone)
Increase respiratory rate, increase heart rate, increase blood pressure
Abstinence syndrome (withdrawal) – hypertension, vomiting, tremors
can cause abstinence syndrome or withdrawal, hypertension, bomiting, tremors. SEIZURES,
can bag, intubate, etc. if appropriate
Opioid Antagonist – Adverse Effects
Monitor vital signs (watch for increase in blood pressure)
Monitor for tachycardia
Have oxygen and resuscitation equipment ready
Expect adverse effects in an opioid dependent patient
have oxygen and resuscitation equipment ready
Opioid Antagonists - Interventions
IM, SC, IV, Intranasal
Titrate doses carefully
Monitor vital signs every 5-15 minutes for several hours
Effects last 60-90 minutes, can need another dose
Be aware that the drug may increase pain by reducing opioid effects and precipitate acute withdrawal for a dependent patient
Opioid Antagonists - Administration
if theyre awake, tell them that you might have to administer it again (even if theyre not awake),
warm patients that they will have pain because it reverses
stimulate before you give ______, but don’t spend a lot of time doing it
Opioid Antagonists – Patient Instructions
Opioid dependence
Respiratory depression due to nonopioid drugs
Opioid Antagonists - Contraindications
Cardiac irritability
Head injury, increased intracranial pressure
Brain tumor
Seizure disorders
Opioid Antagonists - Precautions
Coadministration of opioids
+
alcohol, antihistamines, barbiturates, benzodiazepines, phenothiazine, other CNS depressants
Respiratory Depression
Opioids
+
Monoamine Oxidase Inhibitors
Respiratory Depression, Seizures, Hypotension
Abnormal increase in serum levels of amylase, alanine aminotransferase, alkaline phosphatase, bilirubin, lipase, creatinine kinase, and lactate dehydrogenase
Abnormal decrease in urinary 17-ketosteroid levels
Increase in urinary alkaloid and glucose concentrations
Lab Test Interactions [for opioids ?]
Stimulation
Ventilatory assistance
Opioid Antagonists
Treatment of Overdose? Or Respiratory Depression
Analgesic, Antiinflammatory and Antipyretic Activity
Also for headaches, myalgia, neuralgia, arthralgia, postoperative pain
Relief of pain with rheumatoid arthritis, juvenile arthritis, ankylosing spondylitis, osteoarthritis, gout, hyperuricemia
NSAIDS - Indications
they inhibit prostaglandin synthesis in the CNS and the periphery
NSAIDS
_____ only inhibits in the CNS, NOT the PERIPHERY
ACETAMINOPHEN
What are the NSAIDS?
Aspirin
Ibuprofen (Advil, Motrin)
Naproxen (Naprosyn, Alleve)
Indomethacin (Indocin)
Ketorolac (Toradol)
Inhibit cyclooxgenase (COX)
Two forms of this enzyme =
COX – 1 and COX - 2
NSAIDS – Expected Pharmocologic Actions
______ stimulate release of protective prostaglandins in order to maintain homeostasis in the body
protect gastric mucosa
enhance platelet aggregation
promotes kidney function
COX 1 enzymes
_______stimulates release of prostaglandins in response to injury
inflammation
pain
fever
COX 2
GI tract
Heartburn to GI Bleeding
Acute Renal Failure (especially if dehydrated)
Due to disruption of prostaglandin function
______ block protective effects of COX-1 on the kidneys
Reye’s Syndrome
Salicylism
NSAIDS - Adverse Effects
Monitor for signs of bleeding
Test for and treat Helicobacter pylori infection
Recommend a proton pump inhibitor during NSAID therapy
Monitor I & O, BUN and Creatinine
Monitor for salicylism
With long term use of non-aspirin NSAIDS: Monitor for signs of embolic event
Recommend low dose aspirin to prevent embolic events
NSAIDS -Interventions
Make sure patients swallow enteric coated or sustained release whole
Due to increased bleeding tendencies, discontinue aspirin one week before scheduled surgery
Monitor for initial and continued therapeutic effects
Prophylactic use of aspirin to inhibit platelet aggregation is usually 81mg/day
Administration of NSAIDS
take with food
report gastric irritation
report unusual or prolonged bleeding
report changes in urine output or retention
report edema, bloating, weight gain
don’t give aspirin to kids under 18 who have viral symptoms
report chest pain, shortness of breath, stroke symptoms
report sign of overdose salicylism
first sign is tinnitus
NSAIDS – Patient Instructions
Known drug allergy
Documented Aspirin Allergy should have NO NSAIDS
Risk for bleeding
Vitamin K deficiency
Peptic ulcer disease
Risk for epistaxis
Severe Renal or Hepatic Disease
Chronic Alcohol Abusers
Children and Adolescents with viral infections (Reye’s)
Pregnancy
1 week prior to surgery
NSAIDS - Contraindications
Blocks pain centrally and peripherally
Decrease responsiveness to pyrogens
Anti-platelet activity (bleeding risk)
Toxicity above 300 mcg/mL
Pain that is low to moderate
Gastric upset
Aspirin
______ is a salicylate, it blocks pain centrally and peripherally, decreases responsiveness to pyrogens (substances that cause fever) by acting on the hypothalamus, prevents prostaglandin from increasing inflammation, also have an antiplatelet activity (bleeding risk) cetyle portion of aspirin binds to COX1 and keeps platelets from sticking together
Fever
inflammation
antiplatelet activity
toxicity above 300 mcg/mL
acute ingestion can cause toxicity
low to moderate pain
take with food if gastric upset occurs
aspirin
High risk of overdosing-
Avoid for 2 weeks before and after surgery
Reduce or avoid alcohol
Childproof container
Full glass of water with food
Report signs of bleeding
Don’t exceed recommended dose
Patient Teaching for Aspirin
Removing salicylate from the GI tract
Preventing Further absorption
Correcting fluid, electrolyte and acid-base disturbances
Implementing measures to enhance _____ elimination = dialysis
GI tract: pump stomach
correct fluid and electrolyte and acid base disturbances
elimination can be done through dialysis
Management of Salicylate Overdose
Very bound to plasma proteins
Tablets, chewables, suspension and drops
Maximum of 2400 mg/day
Used in osteoarthritis, rheumatoid arthritis
Used to treat pain and fever
ibuprofen
Symptoms: drowsiness, lethargy, mental confusion, paresthesias, numbness, aggressive behavior, disorientation, seizures and gastrointestinal toxicity
dialysis does not help, activated charcoal must be used and will bind with _______, it is done through an NG tube
ibuprophen,
Nonsalicylate NSAIDS Toxicity
Similar to Salicylate Overdose but usually not as extensive or dangerous
Analgesia for mild to moderate pain
Inflammation suppression
Fever reduction
Dysmenorrhea
NSAIDS (COX-2) - Indications
embolic event potential associated with _____
causes vasoconstriction and increased platelet aggregation
GI upset and renal failure as well as cardiac events are possible with this medication, as well as renal dysfunciton
COX 2 inhibitors
celecoxib
Monitor for and report gastric upset, heartburn, nausea, diarrhea, GI bleeding
Test for and treat H. pylori infection prior to long term therapy
For patients at high risk for gastric bleeding, recommend a proton pump inhibitor
Monitor I&O, watch for decreased urine output and fluid retention
Monitor for rapid rises in BUN and creatinine (important)
Recommend drug for short periods and in low doses only to minimize side effects
Monitor for MI and CVA, give low dose aspirin to prevent events
NSAIDS (COX-2) - Interventions
give aspirin a day if at risk for embolic event if they can tolerate it
give with food, water, milk if having GI issues
avoid alcohol
persistent GI irriation or problems, call their doctor
kidney: change in urine output, fluid retention, call the doctor
and S&S of MI or CVA, call doctor and ambulance
NSAIDS (COX-2) – Patient Instructions
Pregnancy Risk Category D (3rd trimester) – can cause premature closure of ductus arteriosus
Severe hepatic or renal impairment
Children < 19 year
GI bleeding, anemia
Pain from coronary bypass grafting
Allergy to sulfa, sulfonamides, or ______
NSAIDS (COX-2) - Contraindications
celecoxib
For mild to moderate pain
Great alternative to aspirin
Antipyretic drug of choice for adolescents and children with flu syndromes
Avoids risk of Reyes syndrome associated with aspirin use
doesn’t have antiplatelet effects
blocks peripheral pain by inhibition of prostaglandin synthesis
has zero anti-inflammatory properties
fewer side effects with ______
doesn’t affect coagulation: does not have cardiovascular side effects
Does not cause GI isrritation
Acetaminophen - Indications
Blocks peripheral pain by inhibition of prostaglandin synthesis
Lowers febrile body temperatures by acting on the hypothalamus
No anti-inflammatory properties (Not NSAID)
Fewer side effects
No interference with coagulation
Acetaminophen – Expected Pharmacologic Actions
Liver damage (overdose)
Hypertension (with daily use, particularly women)
Acetaminophen –Adverse Effects
Monitor for early symptoms of overdose/poisoning
Prepare to administer acetylcysteine (Mucomyst, Acetadote) orally or IV to counteract overdose and reduce liver injury
Monitor blood pressure in patients, particularly in women who take acetaminophen regularly
Acetaminophen - Interventions
Potentially lethal if overdosed
Results in hepatic toxicity
Acute hepatotoxicity can usually be reversed with acetylcysteine
Long term hepatotoxicity is likely to be permanent
Maximum daily dosage for healthy adults = 3g (some will still say 4g? FDA (2014))
Toxicity and Management of Acetaminophen Overdose
Given orally, IV or rectally
Do not administer > 3g/day to adults and children over 12 years of age
Infants and children should be given the manufacturers recommended dose based on age
Caution patients about OTC
will not prevent a heart attack or stroke
Acetaminophen - Administration
Doesn’t cause gastric irritation or bleeding
Won’t relieve inflammation
Won’t prevent heart attack or stroke
Watch OTC labels (do not exceed 3g/day)
Don’t exceed recommended dose or duration
Avoid alcoholic beverages
Report abdominal discomfort, N/V, sweating, diarrhea immediately
Check BP often (especially in women)
Watch dosages and measure carefully, especially for children
Patient Teaching: Acetaminophen
Drug allergy
Severe liver disease
Genetic disease = glucose-6-phosphate dehydrogenase deficiency
Alcoholism
Acetaminophen Contraindications
Moderate to moderately severe pain
Centrally Acting Nonopioid - Indications
What are the uricosurics?
allopurinol
febuxostat
probenecid
allopurinol
uricosurics
febuxostat
uricosurics
probenecid
uricosurics
Inhibit Xanthine oxidase (XO) from converting hypoxanthine and xanthine to uric acid
Block formation of uric acid
Allopurinol and Febuxastat
Inhibits tubular reabsorption of uric acid in kidneys
Promotes excretion of uric acid
Probenecid
Hypersensitivity syndrome (fever, rash, eosinophilia, liver and kidney dysfunction)
GI disturbances (N/V, diarrhea)
Drowsiness, headache, vertigo
Agranulocytosis (decreased white blood cells), aplastic anemia, bone marrow depression
Metallic taste in mouth ( causes people to not want to eat)
Cataracts (with drugs therapy > 3 years)
Uricosurics – Adverse Effects
Monitor for symptoms of hypersensitivity syndrome
If fever or rash develop stop medication immediately and check liver and kidney function
Monitor for worsening GI effects
For vomiting, ensure adequate hydration
Give drug after meals
Monitor patients for drowsiness or vertigo – fall risk
Monitor CBC, liver, kidney function tests and uric acid levels
Monitor for unusual taste sensations
Recommend regular eye exams
Uricosurics – Interventions
Oral or IV
Monitor uric acid levels (initially, every 1-2 weeks to establish appropriate dosage)
Obtain baseline CBC and test liver and kidney function and monitor periodically
Allow crushing tablets, mixing them with food or liquid
Administer IV using recommended dilution and infuse over 30-60 minutes
Make sure patient drinks at least 3L per day
Uricosurics – Administration
report : fever, rash, abdominal pain
3 liters of fluid or more per day
avoid driving or activities that require mental alertness until they know if med is going to cause drowsiness
if causes a headache, try OTC medicine
report bleeding, easy bruising, sore throat, aemias, bone marrow suppression
protect their eyes from sunlight bc theyre at higher risk for cataracts
need to report blurred vision and see eye doctor regularly
contraindication: hypersensitive to medicine itself
renal impairment
Uricosurics – Patient Instructions
Hypersensitivity to Allopurinol
Avoid in patients with renal impairment
Uricosurics – Contraindications
Symptomatic relief of pain and inflammation in both inflammatory and autoimmune disorders
Management of many skin disorders, allergic reactions
Delay of progression of some disorders like rheumatoid arthritis
Prevention of organ rejection
Adjunctive therapy for some cancers
Glucocorticoids - Indications
______ Inhibit synthesis of prostaglandins which decreases pain
They decrease permeability of capillaries which decreases swelling
ihibit lysosomal activity which decreases inflammation
decrease production of lymphocytes which decreases immune response
Glucoccorticoids
Suppression of adrenal function
Hyperglycemia
Myopathy
Peptic ulcer disease, GI discomfort
Infection
Fluid and electrolyte imbalances
Fat redistribution
Bone loss
Cataracts
glucocorticoids
Increase doses during stress or illness
Monitor blood glucose especially in diabetic patients
Adjust dosages of insulin and oral hypoglycemics as needed
Observe for GI bleeding
Protect GI, give med with food and recommend not using an NSAID
Observe for signs of infection
Regular eye exams
Glucocorticoids - Interventions
Orally, IV, IM, SC, topically, intranasally, inhalation
Short term – largest dose on first day and taper for 8 days
Long term – (10 or more days) take in the morning and use alternate dosing
Taper dose slowly when symptoms are controlled to establish lowest possible dose
Give supplemental doses as needed for times of stress
Glucocorticoids - Administration
Systemic fungal infection
cataracts
Glucocorticoids - Contraindications
Reduces nervousness, excitability, irritability
Does not cause sleep
sedative
Causes sleep, drowsiness
hypnotic
______ work by causing relaxation, know that it calms and relaxes the central nervous system.
Benzos
______ can cause addiction, less likely to be given routinely because it causes people to become addicted to the med
Benzos
Anxiety
Insomnia
Seizure disorders
Muscle spasm
Alcohol withdrawal (blood pressure/autonomic hyperactivity)
Preoperative relief of anxiety
benzodiazepines therapeutic uses
CNS Depression
Respiratory depression
Abuse potential
Paradoxical effects: Rebound anxiety effects, insomnia, excitation
adverse effects associated with benzodiazepines
Most of these meds are not good for elderly people because of high fall risk and the potential for the drug to build up in their system, psychosis, glaucoma, kidney dysfunction, alcohol intoxication (causes system to slow down, resp depression), pregnancy
_____ ARE NOT TO BE GIVEN LONG TERM, PRIMARILY SUPPOSE TO BE GIVEN SHORT TERM
if patient is taking a _____ and have to stop taking it, you have to taper off, you cant just stop cold turkey, they will have withdrawal
Avoid activities that require focus and attention, the meds make you groggy and less able to pay attention, they shouldn’t be driving
BENZOS
Psychosis
Acute narrow angle glaucoma
Renal (kidney) or hepatic (liver) dysfunction
Acute alcohol intoxication
Pregnancy
contraindications with benzos
Longer the use, higher the dose
the shorter acting, the more likely
occurs most often 4-5 days after discontinuation
Benzodiazepine withdrawal
Early signs:
Lack of coordination, lightheaded
Slowed or slurred speech
Other cognitive impairments (drowsy, anterograde amnesia, confusion)
Late signs:
Poor judgment
Slowed breathing
Slowed heart rate
Confusion
Lethargy
CNS depression
Benzos cause CnS depression if you take too many
if you give an IV infusion of a ______ it can cause cardiac arrest if you give it too fast, IV administration has to be given very slow
benzo
Short‑term use: anxiety, insomnia, tremors and dizziness
Long‑term use: delirium, paranoia, panic, hypertension and seizures
Reduce dose by 10-25% every 1-2 weeks over 4-16 weeks
Monitor client carefully when tapering
benzodiazepine withdrawal
Altered Mental Status
Bradycardia (Heart rate below 60)
Unable to walk or coordinate movements (ataxia)
Speech garbled or slurred
Experience hallucinations or memory loss
Decreased respirations
s/s of toxicity from benzos
Oral overdose: Drowsiness, lethargy, excessive sedation/coma, respiratory depression, reduced muscle coordination and confusion
Intravenous overdose: Life-threatening reactions, profound hypotension, respiratory arrest, and cardiac arrest
General treatment measures
Oral: Gastric lavage, activated charcoal, saline cathartic, and dialysis
benzo acute toxicity/treatment
_________competes with the same receptor as benzodiazepines
Approved for benzodiazepine overdose and for reversing the effects of benzodiazepines after general anesthesia
Quick acting: 1-2 minutes, Peak 6-10 minutes
Short duration: repeated dosing needed
Dose depends on the problem: suspected overdose? Reversal of conscious sedation or Anesthesia? Look at unbound
Flumazenil
Flumazenil only works on _____
BENZOS
Sedative-hypnotic
Most widely used hypnotic
Short-term management of insomnia
Side effects: Daytime drowsiness and dizziness
Administer just before bedtime
CR is approved long term
Zolpidem [Ambien], Zolpidem Tartrate [Ambien CR
Benzo like drugs
Many take these at bedtime
Do some funky things to elderly, increased confusion (increased falls)
Most widely used hypnotic
for short term management of insomnia
CR is approved for long term
ADMIN JUST BEFORE BEDTIME, they can have daytime drowsiness or dizziness, may be groggy in the mornings, the Controlled release has two different drug reservoirs one has meds to have go to sleep and the other has stuff to help them stay asleep
Zolpidem
Zolpidem tartrate
Chronic anxiety
Gradual onset
Must be tapered
Take with food to increase drug effectiveness
______ can be used to manage chronic anxiety, is not a Benzo, don’t need to know specifically how it works
Benzos work very quickly, but ______ doesn’t work that way it takes weeks for it to start affecting your anxiety to the point that you would actually know it
______ is now for acute anxiety, the med works over a period of time
_______ needs to be tapered off
if they take it with food, it increases the effectiveness of med
Buspirone
New class of hypnotics, pyrazolopyrimidines
Short-term management of insomnia
Prolonged use does not appear to cause tolerance
Most common side effects: Headache, nausea, drowsiness, dizziness, myalgia, and abdominal pain
zaleplon
For treatment of insomnia
No limitation on how long it can be used
Most common adverse effect: Bitter aftertaste
Other common side effects: Headache, somnolence, dizziness, and dry mouth
eszopiclone
Herbal product
Not subject to FDA regulation
Don’t combine with other CNS depressants
May increase bleeding risks with anticoagulants
melatonin
Causes tolerance and dependence
High abuse potential
Multiple drug interactions
Powerful respiratory depressants that can be fatal with overdose
Rapid onset and brief duration
CNS depression
Cardiovascular effects
barbiturates
not for home use, they’ll be given in the hospital,
______: cause tolerance and dependence, high abuse potential, many drugs interactions, powerful respiratory depressants, given rapidly and have short duration, CNS depression, not recommended for sleep aid, can cause heart attack, increased risk of fall, deprive people of REM sleep
Barbiturates
Acute Toxicity Symptoms
Respiratory depression
Coma
Pinpoint pupils
Treatment
Removal of ______ from the body (activated charcoal)
Maintenance of an adequate oxygen supply to the brain
Maintain body heat
Support blood pressure
No specific antidote
barbiturate
sedative hypnotic
onset 30 minutes
works for both difficulty falling asleep or difficulty staying asleep
may alter digoxin levels
grapefruit juice increases blood levels and sedation
may cause complex sleep behaviors –sleep walking, eating, or driving
suvorexant - sedative hypnotic (non Benzo)
Multiple seizures occur with no recovery between them.
Result: hypotension, hypoxia, brain damage, and death
True medical emergency
Basic Nursing Care
status epilepticus
what is the drug of choice for status epilepticus?
IV lorazepam
if no IV access, what drug is used for status epilepticus?
rectal diazepam or nasal midazolam
Slows down movement of electrolytes
Sodium, potassium, calcium, magnesium
Decreases the speed of nerve impulses
Cell membranes become less excitable
Increases the seizure threshold
Limits the spread of seizures to different areas
Some types enhance GABA effects
antiepileptic/convulsant medications MOA
Control or prevent seizures
Maintain a reasonable quality of life
70% are seizure free with just one medication
30% are more complex, may require several medications
goals of therapy for antiepileptics
Highly individualized medication regimen
Life-long medication management
Serum drug concentrations must be monitored
Therapeutic drug range is flexible
nursing actions for antiepileptic drugs
What is the therapeutic range for phenytoin?
10-20 mcg/ml
Adverse effects: gingival hyperplasia, acne, hirsutism, Dilantin facies, and osteoporosis
CNS effects: Sedation, blurred vision, cognitive impairment
Decreases synthesis of Vitamin D
Skin and Cardiovascular problems
Administer at slow IV rate (no faster than 50 mg/min) and ONLY with normal saline
adverse effects of phenytoin
Usually well tolerated, effective at treating seizures, and relatively inexpensive.
Half life allows for twice or even once a day dosing which encourage adherence.
advantages of phenytoin
Intravenous (IV) administration
Very irritating to veins
Slow IV directly into a large vein through a large-gauge (20-gauge or larger) venous catheter
Diluted in normal saline (NS) for IV infusion
Filter must be used
Saline flush
phenytoin administration
Inject IV form slowly
No more than 50mg/min
In older adults give 25mg/min
Therapeutic ______ level 10-20 mcg/mL
Lower if malnourished or renal failure
STRICT ADHERENCE to medication regimen
Do not abruptly d/c = withdrawal symptoms, may trigger seizures
Highly protein bound
Phenytoin nursing notes
What is the therapeutic level for carbamazepine?
4-12 mcg/ml
May need to increase dose after 2 months due to autoinduction
CNS effects (vision problems, vertigo)
Risk for fluid overload – a nursing diagnosis
Blood cell problems (leukopenia, anemia, thrombocytopenia)
Skin disorders from mild to severe
carbamazepine
What is the WBC normal range?
4500-1100
What is the platelets normal range?
150000-450000
What antiepileptic drug is associated with thrombocytopenia/blood disorders?
carbamazepine
(also valproic acid causes thrombocytopenia)
White blood cells (WBC) – 4500-11000 WBC/microliter
Complete blood cell count
Platelets – 150000-450000 platelets/microliter
Do NOT mix with other oral drug suspensions
Avoid grapefruit with ______
Sore throat, fever, easy bruising (signs of bone marrow suppression
carbamazepine
What is the therapeutic level of valproic acid?
50-100 mcg/ml
General GI problems (N/V, indigestion)
Hepatotoxicity Hepatitis
Decreased appetite, abdominal pain, jaundice, n/v, liver function labs
Pancreatitis
Nausea, vomiting, and abdominal pain, changes in amylase levels
CNS effects from hyperammonemia
Thrombocytopenia
Bruising, bleeding, prolong the bleeding times, decrease the platelets
valproic acid
Labs to monitor
Hepatotoxicity: Liver function labs (next slide)
Pancreatitis: Changes in amylase levels (Normal: 30 to 110 units per liter (U/L))
Hyperammonemia: Normal Ammonia range: 15 to 45 µ/dL (11 to 32 µmol/L)
Thrombocytopenia: Platelets normal range: 150,000 to 450,000
Administer slowly
Dilute the IV form in at least 50ml of NS 0.9%
Do not mix with other drugs in solution
nursing notes for valproic acid
Contraindication:
Pregnancy*
Bone marrow suppression (Gabapentin)
Within 14 days of taking a MAOI (Gabapentin)
contraindications with newer antiepileptics
CNS effects
Suicidal ideation – worse with Lamotrigine (Lamictal)
Skin disorders – mild to life threatening
Multiorgan hypersensitivity reaction with Oxcarbazepine
adverse effects of all newer AEDs
Headache, dizziness, nausea
Rash Multi-organ hypersensitivity
Fever with some or all of the following: lymphadenopathy, hepatorenal syndrome, hematologic abnormalities
oxcarbazepine specific adverse reactions
Contraindications: drug allergy
Common side effects: relatively minor CNS and GI symptoms
Adverse effects:
Aseptic meningitis: headache, fever, stiff neck, nausea, vomiting, rash, sensitivity to light
Steven-Johnson syndrome
Thrombocytopenia
Changes in seizure
side effect/adverse effects associated with lamotrigine
Adverse effects: similar CNS and GI symptoms as previous meds, increased bleeding/bruising/nosebleeds (thrombocytopenia), changes in menstrual cycle, osteoporosis/rickets
topiramate adverse effects (similar to all of the newer AEDs I think)
Loss of pleasure or interest (anhedonia)
Insomnia (or sometimes hypersomnia)
Anorexia (or sometimes hyperphagia)
Mental slowing and loss of concentration
Feelings of guilt, worthlessness, and helplessness
Thoughts of death and suicide/overt suicidal behavior
Symptoms must be present most of the day, nearly every day, for at least 2 weeks
clinical features of depression
Symptoms resolve slowly
Initial responses develop after 1 to 3 weeks
Maximal responses may not be seen for 12 weeks
Failure when taken 1 month without success
considerations for all antidepressants
May increase suicidal tendencies during early treatment
Patients should be observed closely for the following:
Suicidality
Worsening mood
Changes in behavior
Precautions
Prescriptions should be written for the smallest number of doses consistent with good patient management
Dosing of inpatients should be directly observed
considerations for all antidepressants
Begins 2 to 72 hours after treatment
Altered mental status (agitation, confusion, disorientation, anxiety, hallucinations, and poor concentration)
Incoordination, myoclonus, hyperreflexia, excessive sweating, tremor, and fever
Deaths have occurred
resolves spontaneously after discontinuing the drug
Risk increased by concurrent use of MAOIs and other drugs
serotonin syndrome (associated with SSRIs)
Early symptoms:
Nausea, diaphoresis, tremor, nervousness, *Suicidal ideation (SI)
Later symptoms:
Sexual dysfunction, weight fluctuation, *Serotonin Syndrome, GI bleed, hyponatremia, bruxism, orthostatichypotension
SSRI adverse effects
monitor platelets
elderly or renal impaired may need lower dose
can take 1-3 weeks to work
sodium labs esp if taking diuretic
may need to d/c in pregnancy or 3rd trimester
do not d/c abruptly - withdrawal symptoms
nursing notes for SSRIs
Caution:
Serotonin Syndrome* (SSRIs, TCAs)Hx of bipolar disorder, mania, seizure disorder, recent MI, or interstitial lung disease
Contraindication:
MAOIs within 14 days Renal OR Hepatic impairmentEspecially with substantial alcohol use/abuse
SNRI caution/contraindication
Fatigue/drowsiness or paradoxical effects (insomnia, anxiety, HTN, tachycardia)
Decreased appetite or weight loss, nausea
Sexual dysfunction
Hyponatremia (duloxetine)
Respiratory Issues (venlafaxine)
SNRI adverse effects
Serotonin Syndrome Hepatotoxicity
Seizures Suicidal ideation
life threatening SNRI adverse effects
Do not abruptly d/c – withdrawal symptoms
Take in the morning if interrupts sleep
Take with food if it causes upset stomach
Avoid MAOIs
Obtain baseline sodium levels for older adult clients taking diuretics, monitor periodically- normal range is 135 and 145 milliequivalents per liter (mEq/L)
SNRIs
MAOIs within 14 days Renal OR Hepatic impairmentEspecially with substantial alcohol use/abuse
contraindications for SNRIs
Fatigue/drowsiness or paradoxical effects (insomnia, anxiety, HTN, tachycardia)
Decreased appetite or weight loss, nausea
Sexual dysfunction
Hyponatremia (duloxetine)
Respiratory Issues (venlafaxine)
SNRI adverse effects
- original first generation antidepressants
How it Works:
Blocks reuptake of norepinephrine & serotonin
Corrects imbalance
Used For:
Treatment resistant Depression
Painful neuropathy
TCA antidepressants
Contraindication
Use of MAOIs
Seizures
Recent MI
contraindications for TCAs
Constipation
Urinary retention
Blurred vision, photophobia
Dry mouth
Tachycardia
Feel hot, dry
Confusion
Cardiovascular effects
Cardiac conduction problems (dysrhythmias)
Hypotension
S/S of Toxicity/Overdose
Cardiac dysrhythmias, mental confusion, agitation followed byseizures, coma, and possible death
Adverse effects with TCAs
Therapeutic effects within 2-3 weeks
Full therapeutic effects can take 2-3 months
How to manage side effects (anticholinergic)
Assess for suicidal ideation, weight gain, and orthostatic hypotension
Nurse notes for TCAs
How it Works:
Inhibits MAO enzyme
Enzyme no longer can metabolize (many) neurotransmitters
Method of action for MAOIs
Caution
Large amounts of caffeine, cough/cold meds, diet pills (stimulants)
Diabetes and seizure disorders
Moderate levels of ______ foods: Yogurt, bouillon, non aged cheese (cottage cheese, mozzarella), bananas, red wine, fava beans
Tyramine
MAOIs interact with tyramine
Contraindication
Heart failure, cardiovascular and cerebral vascular disease, and severe renal insufficiency
MANY medications and OTC (ex. Meperidine)
High levels of tyramine rich foods: Aged cheese (blue, swiss, cheddar), smoked/pickled/aged meats, yeasts, etc.
Contraindications with MAOIs, also tyramine
CNS stimulation
Blood pressure changes
Orthostatic HYPOtension
Or HYPERtensive crisis
Hypertensive Crisis
Severe hypertension, severe headache, nausea, increased apical heart rate, chest pain
Most common in “Non-selective” ______
Serotonin Syndrome
MAOIs adverse effects
Goal: Protect brain and heart
Game Plan: Eliminate the ______
How: Phentolamine (Regitine) or nifedipine SL (Procardia)
Monitor cardiac function
Continuous monitoring not just an EKG
Monitor and support respiratory function
MAOI
d/c 14 days before anesthetics and other antidepressants
can take several weeks before therapeutic effects are seen
educate patient about tyramine rich foods andinteractions with many medicaitons
MAOI nursing notes
Reduce pain sensation at level of peripheral nerves
local anesthetics
Block sodium channels and conduction
local anesthetics
Block sodium channels and conduction
local anesthetics
Topical anesthetic
Indications: postherpetic neuralgia/before IV start
Left in place no longer than 12 hours
Minimal adverse effects
Local/Regional Anesthetic
Duration 60-75 minutes
Max dose 4 mg/kg or 7 mg/kg with epinephrine
Toxic IV dose: 250 mg
xylocaine
Advantages
Effective alternative to GA
Avoids polypharmacy
Patient can remain awake
Early drink/feed
Disadvantages Limited scope Higher failure rate Time constraints Anticoagulants Risk of neural injury
local anesthetics
_____ is often administered with the local anesthetic (lidocaine with ______ for example)
_____ also decreases local blood loss
Epinephrine
Damage to the nerve
Persistent numbness, weakness, or pain
Rare
Risk of systemic toxicity
Other complications: infection, swelling, or bruising (hematoma) at the injection site.
Spinal administration only: “spinal headache
Risks for regional anesthetics
- blocks a nerve or small bundle of nerves
Peripheral regional
Blocks large area- causes loss of sensation of pain and paralysis to the area.
Not as risky as general- doesn’t cause loss of consciousness.
Regional Central
Doesn’t cause complete loss of consciousness
Does normally cause respiratory arrest
Increasing due to more office/outpatient surgery centers
Allows patient to relax; reduces anxiety- airway intact; can follow commands, more rapid recovery than general anesthesis.
Most commonly used= short acting benzodiazepine- midazolam (versed) usually given with short acting opoid (fentanyl or morphine
moderate Sedation or procedural sedation
doesn’t do anything for pain, just used for sedation
if a patient routinely dirnks alcohol, you might need a higher dose
have to be certified to monitor patient in conscious sedation
doesn’t do anything for pain, just used for sedation
if a patient routinely dirnks alcohol, you might need a higher dose
have to be certified to monitor patient in conscious sedation
Midazolam (Versed)
Apnea, respiratory depression, post-op respiratory depression
Tends to reduce BP and peripheral vascular resistance more than Diazepam
Adverse reactions associated with midazolam
Aids intubation
Surgery of long duration
Reduces maintenance dose of anesthetics agents
Muscle relaxants
Prevent nerve transmission in skeletal and smooth muscle leading to paralysis
In conjunction with general anesthesia- diaphragm paralysis & intercostal muscles
High alert drugs- sound alike drugs= restricted access to these drugs
Neuromuscular blocking drugs
Reversible, unconscious state
Physical assessment findings: amnesia, analgesia, depression of reflexes, muscle relaxation, person is unconscious
_______ usually uses a combination of IV drugs and inhaled gasses
General anesthesia
Given IV
Often inhaled anesthetics used as well
Adjunct drugs are used
Parenteral anesthetics
Advantages
No absolute contra-indication
Quick to establish
Never fails to work
Disadvantages
Poly-pharmacy
Effects many systems
Post operative N/V
General Antethesia
Extubate once awake
Check of gag reflex
Always have suctioning equipment available
Nursing notes for general anesthesia
